Crash of a PZL-Mielec AN-2TP near Rocca di Mezzo: 3 killed

Date & Time: Mar 9, 2002 at 1339 LT
Type of aircraft:
Registration:
LY-AVD
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Budapest - Tunis
MSN:
1G137-53
YOM:
1972
Flight number:
SJK2801
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft departed Budapest-Ferihegy Airport at 0829LT on a VFR flight to Tunis. According to the flight plan the aircraft would fly over Split, Pescara, crossing the Apennines towards Ostia and then onwards to Tunis. Weather conditions over the central part of Italy were poor with a cold front associated with thunderstorm activity, low clouds and icing conditions. After passing over the Adriatic sea, the aircraft overflew Pescara at 1320LT where the pilot informed ATC that the aircraft was inbound Aneda (a reporting point 19 NM East of Monte Rotondo) at a cruising altitude of 5.500 feet. While in vicinity of Pescara, ATC requested and obtained confirmation from the crew that he was able to continue under VFR mode. Shortly later, at a speed of 115 knots, the single engine aircraft struck the slope of Mt Rotondo (1.880 metres high) located near Rocca di Mezzo. The aircraft disintegrated on impact and all three occupants were killed.
Probable cause:
Analysis of available evidence make it reasonable to classify the event investigated as an unintentional terrain impact, Controlled Flight Into Terrain (CFIT). At accident time, because of the reduced visibility, incompatible with VFR flying, the crew could not evaluate correctly the orography of the area along there route. It has to be noted that it was not possible to ascertain if adequate maps were available to the crew showing the exact position of ground relief and obstacles. It was not possible to determine if the pilots had flown across the same area in the past. Given the meteorological conditions over the area, the crew did not conform to the Visual Flying Rules that mandated for a track change to maintain the required flight parameters (visibility/clearance from obstacles) and/or a diversion to a suitable alternate airport (as international rules mandate).
Contributing factors:
Analysis of available evidence suggests that the following may be considered as contributory factors to the accident. The prevailing meteorological conditions existing on March 9, 2002 over the flight path of LY-AVD across the central part of Italy did not allow for the flight to be continued under VFR. The Antonov AN-2 was not fit for flying in low visibility (IMC) and was not equipped for flying in icing conditions. The pilot of the LY-AVD did not hold the required English language radio-telephony (RT) qualification to operate outside the country of licensing. The pilot of the LY-AVD did not hold an IFR qualification (for flying in IMC).
Final Report:

Crash of a Technoavia SM-92G Turbo Finist in Thiene

Date & Time: Feb 3, 2002 at 1630 LT
Registration:
HA-YDG
Survivors:
Yes
Site:
Schedule:
Thiene - Thiene
MSN:
00-004
YOM:
1995
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
500
Captain / Total hours on type:
40.00
Circumstances:
The single engine airplane departed Thiene Airstrip at 1540LT for a local flight, carrying nine skydivers, one observer and one pilot. At the altitude of 13,500 feet, seven skydivers jumped while three others decided to stay in the cabin because the visibility was poor due to foggy conditions. While returning to his departure point, the pilot encountered poor visibility and completed two unsuccessful approach. He eventually decided to divert to Asiago Airport located 24 km from his position but this decision was taken too late. While circling around the airport, the engine failed and the aircraft stalled, struck the roof of a house and crashed in Rozzampia, less than one km east of the airfield. All four occupants were injured and the aircraft was damaged beyond repair.
Probable cause:
The following contributing factors were identified:
- Weather conditions were marginal with thick fog reducing the visibility to 100 metres,
- Poor flight planning as the pilot failed to refuel the airplane prior to departure and ignored the instability of the weather conditions,
- The pilot's decision to divert to Asiago Airfield was taken too late,
- Poor coordination with the people in place at the Thiene Aerodrome,
- The pilot's inexperience.
Final Report:

Crash of a Cessna 525A CitationJet Cj2 in Milan: 4 killed

Date & Time: Oct 8, 2001 at 0810 LT
Type of aircraft:
Operator:
Registration:
D-IEVX
Flight Phase:
Survivors:
No
Schedule:
Cologne - Milan - Paris
MSN:
525A-0036
YOM:
2001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5000
Captain / Total hours on type:
2400.00
Copilot / Total flying hours:
12000
Copilot / Total hours on type:
2000
Aircraft flight hours:
28
Aircraft flight cycles:
20
Circumstances:
A brand new Cessna 525A CitationJet 2, D-IEVX, arrived at Milan-Linate following a flight from Köln. The Cessna was to carry out a return flight to Paris-Le Bourget, carrying two pilots, a Cessna sales manager and a prospective customer. The plane arrived at 06:59 and was taxied to the General aviation apron, also known as 'West apron'. It was a foggy morning at Milan and one of the passenger flights parked on the North apron was SAS MD-87 "Lage Viking" which was being prepared for flight SK686 to Copenhagen, scheduled to depart at 07:35. At 07:41, the pilot of the MD-87 contacted Linate Ground Control for his engine start clearance, as the boarding of 104 passengers had been completed. The Ground controller cleared the pilot to start engines and advised that the slot time for takeoff of the flight was at 08:16. Thirteen minutes later flight 686 was cleared to taxi to runway 36R: "Scandinavian 686 taxi to the holding position Cat III, QNH 1013 and please call me back entering the main taxiway." A few minutes later, the Cessna pilot requested permission to start the engines. The ground controller then gave start-up clearance. The ground controller then requested flight 686 to contact the Tower controller. From this moment on the crew of the MD-87 and the crew of the Cessna were tuned on two different radio frequencies. At 08:05 the pilots of the Cessna received taxi clearance: "Delta Victor Xray taxi north via Romeo 5, QNH 1013, call me back at the stop bar of the ... main runway extension." The pilot acknowledged by saying: "Roger via Romeo 5 and ... 1013, and call you back before reaching main runway." The Cessna started to taxi from the General Aviation parking position, following the yellow taxi line. After reaching the position where the yellow taxi line splits into two diverging directions, the pilot erroneously took the taxi line to right and entered taxiway R6. At 08:09 the Ground controller cleared the Cessna to continue its taxi on the North apron. At the same time the Tower controller cleared the MD-87 for takeoff: "...Scandinavian 686 Linate, clear for take off 36, the wind is calm report rolling, when airborne squawk ident." The pilot advanced the throttles and acknowledged the clearance: "Clear for takeoff 36 at when...airborne squawk ident and we are rolling, Scandinavian 686." When the MD-87 was speeding down the runway, the Cessna crossed the runway holding sign and entered the active runway 18L/36R. At 08.10:21 the nose landing gear of the MD-87 had left the ground and main gears were extending the shock absorbers but the main wheels were still on the ground at an airspeed of 146 knots (270,5 km/h). At that moment the MD-87 crew probably saw a glimpse of the Cessna through the fog and reacted with additional large nose-up elevator. At that moment the MD-87 collided with the CitationJet. The right wing of the MD-87 sustained damage at the leading edge and the right hand main landing gear leg broke off. It damaged the right flap and struck the no. 2 engine which then separated from the pylon. The pilot of the MD-87 gradually advanced the throttles and then the aircraft was airborne for a total of 12 seconds, reaching an estimated height of about 35 feet (11 meters). The left hand engine suffered a noticeable thrust reduction as a result of debris ingestion, which became insufficient to sustain flight. The airspeed had increased up to 166 knots (307,6 km/h), but the MD-87 descended abruptly making contact with the runway with the left hand maingear, the truncated right hand maingear leg and the tip of the right hand wing. Prior to touch down the pilot reduced engine thrust and after ground contact the engine reverse levers were activated and deployed (on the left hand engine only). Maximum available reverse thrust was selected and the brakes applied. The plane skidded past the grass overrun area, across a service road, crashing sideways into a baggage handling building, which partly collapsed. This building was located 20 m/67 feet to the right of the runway, and 460 m/1500 feet from the runway end. Both pilots were German citizens while both passengers were respectively Mr. Stefano Romanello, representative for Cessna Aircraft in Europe and Mr. Luca Fossati, President of the Star food group.
Probable cause:
After analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. The obvious consideration is that the human factor related action of the Cessna crew - during low visibility conditions - must be weighted against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milano Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout.
The following list highlights immediate and systemic causes that led to the accident:
- The visibility was low, between 50 and 100 meters;
- The traffic volume was high;
- The lack of adequate visual aids;
- The Cessna crew used the wrong taxiway and entered the runway without specific clearance;
- The failure to check the Cessna crew qualification;
- The nature of the flight might have exerted a certain pressure on the Cessna crew to commence the flight despite the prevailing weather conditions;
- The Cessna crew was not aided properly with correct publications (AIP Italy - Jeppesen), lights (red bar lights and taxiway lights), markings (in deformity with standard format and unpublished, S4) and signs (non existing, TWY R6) to enhance their situational awareness;
- Official documentation failing to report the presence of unpublished markings (S4, S5, etc) that were unknown to air traffic controllers, thus preventing the ATC controller from interpreting the unambiguous information from the Cessna crew, a position report mentioning S4;
- Operational procedures allowing high traffic volume (high number of ground movements) in weather conditions as were current the day of the accident (reduced visibility) and in the absence of technical aids;
- Radio communications were not performed using standard phraseology (read back) or were not consistently adhered to (resulting in untraced misunderstandings in relevant radio communications);
- Radio communications were performed in Italian and English language;
- Air Traffic Control (ATC) personnel did not realize that Cessna was on taxiway R6;
- The ground controller issued a taxi clearance towards Main apron although the reported position S4 did not have any meaning to him;
- Instructions, training and the prevailing environmental situation prevented the ATC personnel from having full control over the aircraft movements on ground.
Furthermore:
- The aerodrome standard did not comply with ICAO Annex 14; required markings, lights and signs did either not exist (TWY R6) or were in dismal order and were hard to recognize especially under low visibility conditions (R5-R6), other markings were unknown to operators (S4);
- No functional Safety Management System was in operation;
- The competence maintenance and requirements for recent experience for ATC personnel did not fully comply with ICAO Annex 1;
- The LVO implementation by ENAV (DOP 2/97) did not conform with the requirements provided in the corresponding and referenced ICAO DOC 4976.
The combined effect of these factors, contemporaneously present on the 8th of October 2001 at Milano Linate, have neutralized any possible error corrective action and therefore allowed the accident.
Final Report:

Crash of a McDonnell Douglas MD-87 in Milan: 114 killed

Date & Time: Oct 8, 2001 at 0810 LT
Type of aircraft:
Operator:
Registration:
SE-DMA
Flight Phase:
Survivors:
No
Schedule:
Milan - Copenhagen
MSN:
53009
YOM:
1991
Flight number:
SK686
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
104
Pax fatalities:
Other fatalities:
Total fatalities:
110
Captain / Total flying hours:
5842
Captain / Total hours on type:
232.00
Copilot / Total flying hours:
4355
Copilot / Total hours on type:
1978
Aircraft flight hours:
25573
Aircraft flight cycles:
16562
Circumstances:
A brand new Cessna 525A CitationJet 2, D-IEVX, arrived at Milan-Linate following a flight from Köln. The Cessna was to carry out a return flight to Paris-Le Bourget, carrying two pilots, a Cessna sales manager and a prospective customer. The plane arrived at 06:59 and was taxied to the General aviation apron, also known as 'West apron'. It was a foggy morning at Milan and one of the passenger flights parked on the North apron was SAS MD-87 "Lage Viking" which was being prepared for flight SK686 to Copenhagen, scheduled to depart at 07:35. At 07:41, the pilot of the MD-87 contacted Linate Ground Control for his engine start clearance, as the boarding of 104 passengers had been completed. The Ground controller cleared the pilot to start engines and advised that the slot time for takeoff of the flight was at 08:16. Thirteen minutes later flight 686 was cleared to taxi to runway 36R: "Scandinavian 686 taxi to the holding position Cat III, QNH 1013 and please call me back entering the main taxiway." A few minutes later, the Cessna pilot requested permission to start the engines. The ground controller then gave start-up clearance. The ground controller then requested flight 686 to contact the Tower controller. From this moment on the crew of the MD-87 and the crew of the Cessna were tuned on two different radio frequencies. At 08:05 the pilots of the Cessna received taxi clearance: "Delta Victor Xray taxi north via Romeo 5, QNH 1013, call me back at the stop bar of the ... main runway extension." The pilot acknowledged by saying: "Roger via Romeo 5 and ... 1013, and call you back before reaching main runway." The Cessna started to taxi from the General Aviation parking position, following the yellow taxi line. After reaching the position where the yellow taxi line splits into two diverging directions, the pilot erroneously took the taxi line to right and entered taxiway R6. At 08:09 the Ground controller cleared the Cessna to continue its taxi on the North apron. At the same time the Tower controller cleared the MD-87 for takeoff: "...Scandinavian 686 Linate, clear for take off 36, the wind is calm report rolling, when airborne squawk ident." The pilot advanced the throttles and acknowledged the clearance: "Clear for takeoff 36 at when...airborne squawk ident and we are rolling, Scandinavian 686." When the MD-87 was speeding down the runway, the Cessna crossed the runway holding sign and entered the active runway 18L/36R. At 08.10:21 the nose landing gear of the MD-87 had left the ground and main gears were extending the shock absorbers but the main wheels were still on the ground at an airspeed of 146 knots (270,5 km/h). At that moment the MD-87 crew probably saw a glimpse of the Cessna through the fog and reacted with additional large nose-up elevator. At that moment the MD-87 collided with the CitationJet. The right wing of the MD-87 sustained damage at the leading edge and the right hand main landing gear leg broke off. It damaged the right flap and struck the no. 2 engine which then separated from the pylon. The pilot of the MD-87 gradually advanced the throttles and then the aircraft was airborne for a total of 12 seconds, reaching an estimated height of about 35 feet (11 meters). The left hand engine suffered a noticeable thrust reduction as a result of debris ingestion, which became insufficient to sustain flight. The airspeed had increased up to 166 knots (307,6 km/h), but the MD-87 descended abruptly making contact with the runway with the left hand maingear, the truncated right hand maingear leg and the tip of the right hand wing. Prior to touch down the pilot reduced engine thrust and after ground contact the engine reverse levers were activated and deployed (on the left hand engine only). Maximum available reverse thrust was selected and the brakes applied. The plane skidded past the grass overrun area, across a service road, crashing sideways into a baggage handling building, which partly collapsed. This building was located 20 m/67 feet to the right of the runway, and 460 m/1500 feet from the runway end.
Probable cause:
After analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. The obvious consideration is that the human factor related action of the Cessna crew - during low visibility conditions - must be weighted against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milano Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout.
The following list highlights immediate and systemic causes that led to the accident:
- The visibility was low, between 50 and 100 meters;
- The traffic volume was high;
- The lack of adequate visual aids;
- The Cessna crew used the wrong taxiway and entered the runway without specific clearance;
- The failure to check the Cessna crew qualification;
- The nature of the flight might have exerted a certain pressure on the Cessna crew to commence the flight despite the prevailing weather conditions;
- The Cessna crew was not aided properly with correct publications (AIP Italy - Jeppesen), lights (red bar lights and taxiway lights), markings (in deformity with standard format and unpublished, S4) and signs (non existing, TWY R6) to enhance their situational awareness;
- Official documentation failing to report the presence of unpublished markings (S4, S5, etc) that were unknown to air traffic controllers, thus preventing the ATC controller from interpreting the unambiguous information from the Cessna crew, a position report mentioning S4;
- Operational procedures allowing high traffic volume (high number of ground movements) in weather conditions as were current the day of the accident (reduced visibility) and in the absence of technical aids;
- Radio communications were not performed using standard phraseology (read back) or were not consistently adhered to (resulting in untraced misunderstandings in relevant radio communications);
- Radio communications were performed in Italian and English language;
- Air Traffic Control (ATC) personnel did not realize that Cessna was on taxiway R6;
- The ground controller issued a taxi clearance towards Main apron although the reported position S4 did not have any meaning to him;
- Instructions, training and the prevailing environmental situation prevented the ATC personnel from having full control over the aircraft movements on ground.
Furthermore:
- The aerodrome standard did not comply with ICAO Annex 14; required markings, lights and signs did either not exist (TWY R6) or were in dismal order and were hard to recognize especially under low visibility conditions (R5-R6), other markings were unknown to operators (S4);
- No functional Safety Management System was in operation;
- The competence maintenance and requirements for recent experience for ATC personnel did not fully comply with ICAO Annex 1;
- The LVO implementation by ENAV (DOP 2/97) did not conform with the requirements provided in the corresponding and referenced ICAO DOC 4976.
The combined effect of these factors, contemporaneously present on the 8th of October 2001 at Milano Linate, have neutralized any possible error corrective action and therefore allowed the accident.
Final Report:

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Cumiana: 2 killed

Date & Time: Dec 26, 1999
Registration:
HB-FKJ
Flight Phase:
Survivors:
Yes
Schedule:
Cumiana - Cumiana
MSN:
895
YOM:
1993
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single engine aircraft was completing a local skydiving flight on behalf of the Skydiving Club of Cumiana. In flight, the aircraft encountered atmospheric turbulences when a wing detached. The aircraft entered an uncontrolled descent and crashed in a field. Two occupants were killed and two others were injured. The aircraft was destroyed.
Probable cause:
A wing separated in flight and the aircraft broke in two following severe turbulences.

Crash of a Learjet 35A off Genoa: 3 killed

Date & Time: Oct 24, 1999 at 1015 LT
Type of aircraft:
Operator:
Registration:
I-AVJG
Survivors:
No
Schedule:
Milan - Genoa
MSN:
35-189
YOM:
1978
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The aircraft was completing a charter flight from Milan to Genoa with two pilots and one passenger on board, the Director of an Italian Company working for Coca Cola. On approach to Genoa-Cristoforo Colombo Airport, the crew encountered poor weather conditions with low clouds and rain falls. Due to insufficient visibility, the crew initiated a go-around procedure. Few minutes later, while completing a second attempt to land, the aircraft descended too low and crashed in the sea some 8 km short of runway. The aircraft was destroyed upon impact and all three occupants were killed.

Crash of a Mitsubishi MU-300 Diamond I in Parma

Date & Time: Oct 15, 1999 at 1058 LT
Type of aircraft:
Operator:
Registration:
I-VIGI
Survivors:
Yes
Schedule:
Rome - Parma
MSN:
013
YOM:
1981
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While on an ILS approach to Parma Airport in poor weather conditions, the aircraft struck the ground and crashed in an open field about 3,5 km short of runway. All eight occupants were rescued, among them one pilot was injured. The aircraft was damaged beyond repair. The visibility was limited to 800 metres due to foggy conditions.

Crash of a Piper PA-31-310 Navajo C near Pescara: 2 killed

Date & Time: Jul 15, 1999
Type of aircraft:
Operator:
Registration:
G-NAVO
Flight Phase:
Flight Type:
Survivors:
No
MSN:
31-8212031
YOM:
1982
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Following an uneventful cargo flight to Pescara, the crew was returning to UK. Few minutes after takeoff from Pescara Airport, the crew encountered poor weather conditions. Control was lost and the aircraft crashed, killing both occupants.

Crash of a Dornier DO328-110 in Genoa: 4 killed

Date & Time: Feb 25, 1999 at 1230 LT
Type of aircraft:
Operator:
Registration:
D-CPRR
Survivors:
Yes
Schedule:
Cagliari - Genoa
MSN:
3054
YOM:
1995
Flight number:
AZ1553
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
Upon landing at Genoa-Cristoforo Colombo Airport runway 29, the aircraft encountered crosswinds gusting up to 15-18 knots. It landed on one gear only, bounced and landed firmly too far down the runway. The crew started the braking procedure but the aircraft was unable to stop within the remaining distance, overran and came to rest in the sea. A stewardess and three passengers were killed while 18 other occupants were injured, some seriously. Nine people escaped uninjured. The aircraft was destroyed.